Provider Demographics
NPI:1285076752
Name:ROTH, DEBRA (CNP)
Entity type:Individual
Prefix:MRS
First Name:DEBRA
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 S SHOOP AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSEON
Mailing Address - State:OH
Mailing Address - Zip Code:43567-1712
Mailing Address - Country:US
Mailing Address - Phone:419-337-0915
Mailing Address - Fax:419-337-0561
Practice Address - Street 1:606 S SHOOP AVE
Practice Address - Street 2:
Practice Address - City:WAUSEON
Practice Address - State:OH
Practice Address - Zip Code:43567-1712
Practice Address - Country:US
Practice Address - Phone:419-337-0915
Practice Address - Fax:419-337-0561
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-24
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH02261 - NP363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health